2017 RENEWALINFORMATIONFOR DPRLICENSE AND CERTIFICATE … · department of pesticide regulation...
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2018 RENEWAL INFORMATION FOR DPR LICENSE AND CERTIFICATE HOLDERS Dates for Renewal DPR encourages submitting completed renewal applications to DPR by November 1, 2018, to receive your license/certificate by December 31, 2018. If submitted after November 1, you may not receive your license/certificate by January 1. You cannot work legally without a valid license/certificate. Processing time is 60 days. Note that submitting your renewal before October, will ensure you have your license by early December and allow you to renew with the County by the New Year. To check if you’re renewed, go to DPR’s website: <www.cdpr.ca.gov/docs/license/currlic.htm> Address Changes Always notify DPR immediately of any address or name changes. Mailing of Renewal Packets DPR is mailing renewal packets in August to provide sufficient time for license and certificate holders to submit their applications by November 1. Renewal applications must be postmarked on or before December 31, or a late fee applies. If you did not receive your renewal application or lost it, download a renewal packet from DPR’s website: <www.cdpr.ca.gov/docs/license/liccert.htm> or email us and request a copy. Business License Renewal Application The following forms will be included in the renewal packet: • Business Renewal Application • Renewal Information Request • Visa/MasterCard Transaction DPR‐105 Renewal applications must be filled out completely, signed, and submitted with the correct fee. Note: Your qualified applicator must be renewed before your business license can be renewed. Individual License and Certificate Renewal The following forms will be included in the renewal packet: • Renewal Application DPR‐PML‐141 • License/Certificate Renewal Information • CE Records Renewal Summary DPR‐PML‐123 • Visa/MasterCard Transaction DPR‐105 Renewal applications need to be signed and must include the required CE records summary and correct fee. Continuing Education License and certificate holders must keep copies of their CE records for three years. DPR may request copies of your CE records at any time. Submit the CE Records Renewal Summary, DPR‐PML‐123 or a summary record of CE attendance from a third party professional association. Your CE records must include: License/Certificate Holder’s Name License/Certificate Number and Type Course Location Course Title Course Date DPR Course I.D. Number Course hours attended for each CE category Name of instructor or sponsoring organization Your Signature General Information about CE Courses DPR does not track CE hours for individuals, but has the ability to audit CE records. DPR approved CE hours must be obtained during the valid period of the license or certificate. The valid period is listed on the license or certificate (from the ‘date of issue’ until the ‘valid through’ date). NO grace period is given to obtain CE hours. NO CE hours can be carried over to the next renewal period. If renewing multiple licenses or certificates, you only need sufficient CE hours to meet the license with the most CE hours required. Questions about your CE hours? For questions about your CE hours, you must contact the course sponsor or your professional association. See DPR’s website for current or previous years’ courses and sponsors’ contact info: <http://www.cdpr.ca.gov/docs/license/cont_ed_cfm/classes.htm> DPR List Serve Sign up for important information and updates from DPR about Licensing and CE: <www.cdpr.ca.gov/docs/dept/listserv/sub1113.htm>
Transcript of 2017 RENEWALINFORMATIONFOR DPRLICENSE AND CERTIFICATE … · department of pesticide regulation...
2018RENEWALINFORMATIONFORDPRLICENSEANDCERTIFICATEHOLDERS
Dates for Renewal DPRencouragessubmittingcompletedrenewalapplicationstoDPRbyNovember1,2018,toreceiveyourlicense/certificatebyDecember31,2018. IfsubmittedafterNovember1,youmaynotreceiveyourlicense/certificatebyJanuary 1. You cannot work
legally without a valid license/certificate.Processingtimeis60days.
NotethatsubmittingyourrenewalbeforeOctober,willensureyouhaveyourlicensebyearlyDecemberandallowyoutorenewwiththeCountybytheNewYear.
Tocheckifyou’rerenewed,gotoDPR’swebsite:<www.cdpr.ca.gov/docs/license/currlic.htm>
Address Changes Always notify DPR immediately of any address or name changes.
Mailing of Renewal Packets DPR is mailing renewal packets in August to provide sufficient time for license and certificate holders to submit their applications by November 1. Renewal applications must be postmarked on or before December 31, or a late fee applies.
If you did not receive your renewal application or lost it, download a renewal packet from DPR’s website: <www.cdpr.ca.gov/docs/license/liccert.htm> or email us and request a copy.
Business License Renewal Application The following forms will be included in the renewal packet:
• BusinessRenewalApplication• RenewalInformationRequest• Visa/MasterCardTransactionDPR‐105
Renewal applications must be filled out completely, signed, and submitted with the correct fee.
Note: Your qualified applicator must be renewed before your business license can be renewed.
Individual License and Certificate Renewal The following forms will be included in the renewal packet:
• RenewalApplicationDPR‐PML‐141
• License/CertificateRenewalInformation
• CERecordsRenewalSummary DPR‐PML‐123
• Visa/MasterCardTransactionDPR‐105
Renewal applications need to be signed and must include the required CE records summary and correct fee.
Continuing Education LicenseandcertificateholdersmustkeepcopiesoftheirCErecordsforthreeyears.DPRmayrequestcopiesofyourCErecordsatanytime.
SubmittheCERecordsRenewalSummary,DPR‐PML‐123orasummaryrecordofCEattendancefromathirdpartyprofessionalassociation.
YourCErecordsmustinclude: License/Certificate Holder’s Name
License/Certificate Number and Type Course Location Course Title Course Date DPR Course I.D. Number
Course hours attended for each CE category Name of instructor or sponsoring organization Your Signature
General Information about CE Courses DPR does not track CE hours for individuals, but has the ability to audit CE records.
DPR approved CE hours must be obtained during the valid period of the license or certificate. The valid period is listed on the license or certificate (from the ‘date of issue’ until the ‘valid through’ date). NO grace period is given to obtain CE hours. NO CE hours can be carried over to the next renewal period.
If renewing multiple licenses or certificates, you only need sufficient CE hours to meet the license with the most CE hours required.
Questions about your CE hours? For questions about your CE hours, you must contact the course sponsor or your professional association. See DPR’s website for current or previous years’ courses and sponsors’ contact info: <http://www.cdpr.ca.gov/docs/license/cont_ed_cfm/classes.htm>
DPR List Serve Sign up for important information and updates from DPR about Licensing and CE: <www.cdpr.ca.gov/docs/dept/listserv/sub1113.htm>
License or Certificate Type
DPR Staff Name and Contact Information
General Questions
Pest Control Advisers
Rebecca Olson [email protected]
Heather Allen [email protected] Qualified
Applicator License/ Certificate Elizabeth Dummert
Pest Control
Alpha: A‐D, S,T, U‐Z Regina Maglia
Businesses Alpha: E‐L, M‐R, V Shernee Tousant
Pilots (APC/JPC) Regina Maglia
Dealer Designated Agents
Elizabeth Dummert [email protected]
DEPARTMENT OF PESTICIDE REGULATION PEST MANAGEMENT AND LICENSING BRANCH
STATE OF CALIFORNIA
INDIVIDUAL LICENSE/CERTIFICATE RENEWAL APPLICATION
LICENSING AND CERTIFICATION PROGRAMP.O. BOX 4015
DPR-PML-141 (REV.6/15) SACRAMENTO, CALIFORNIA 95812 Page 1 of 2 (916) 445-4038
Web site:http://www.cdpr.ca.gov/
Return application and continuing education (CE) hours by mail.
The mailing address indicated on this application is your address of record for your license/certificate, therefore, it is public information. To use a post office box in lieu of the physical address or to submit any other address change, indicate in box below.
Name Change Address Change
Name:
Address:
City, State, Zip:
Enter changes above
FOR COMPLETE INSTRUCTIONS, SEE PAGE 2 CE HOURS MUST BE COMPLETED BY THE EXPIRATION DATE ON YOUR LICENSE/CERTIFICATE
Continuing Education. - Excess "Laws" and "Aerial" hours can be used towards your "Other" hours- DPR does not keep record of individual hours
Current License/Certificate Number(s), Type and Category(ies)
Renewal License/
Certificate? (Circle Y or N)
Required CE hours to renew all licenses and certificates
(You need to submit to DPR)
Renewal Fees
Late Fees
Laws Aerial Other Total CE
Hours Post-marked
on or before 12/31
Post-marked after 12/31 (see page 2)
Y / N $
Y / N $ Y / N $ Y / N $
Laws Aerial Other Total CE
Hours Total Due
(Include late fees if applicable)
Enter the number of CE hours you have completed
Fees. ALL FEES ARE NON-TRANSFERABLE AND NON-REFUNDABLE.
Medical Certificate Card. Apprentice and Journeyman Pilots only.
Email Contact (optional). If email is your preferred method of contact, please provide your email address below.
EMAIL ADDRESS
I declare under penalty of perjury, under laws of the State of California, that the above information is true and correct.
SIGNATURE DATE SIGNED
STATE OF CALIFORNIA
INDIVIDUAL LICENSE/CERTIFICATE RENEWAL APPLICATION INSTRUCTIONSDPR-PML-141 (REV. 6/15) Page 2 of 2
Failure to complete or provide the requested information will delay the processing of your application.
INSTRUCTIONS: Review the following to ensure that your renewal application is complete before mailing:
Change of Name/Address. 3CCR Section 6508 requires all license/certificate holders to notify DPR immediately of any business name or address change. Submit required documentation for a name change. Indicate any corrections on the front of the renewal form in the space provided.
License(s)/Certificate(s) to be renewed. Verify or list all license(s) and/or certificate(s) to be renewed.
Submit a record of the total continuing education (CE) hours. - CE hours must be DPR approved courses and obtained during the valid period of your license/certificate.- Excess CE hours cannot be carried over to your next renewal period.- You must meet the minimum required CE hours for “Laws,” and “Aerial,” if required; extra hours in “Laws” and/or “Aerial”may be applied towards “Other”.If renewing multiple licenses/certificates:- If renewing multiple licenses or certificates, you only need to complete CE hours for the license or certificate with themost CE hours required.- Complete and submit the Continuing Education Record Renewal Summary or a similar form.
Medical Certificate Card (Apprentice and Journeyman Pilots Only). Submit a copy of your valid medical certificate card issued by the Federal Aviation Administration. DPR requires this information to determine compliance with Food and Agricultural Code Section 11901.
Fees. All fees are non-transferable and non-refundable. Fees must be paid for each renewed license and/or certificate. A late penalty fee of fifty percent (50%) of the renewal fee will be assessed for each license and/or certificate postmarked after December 31.
License Renewal (2 Year) and Late Penalty Fees License Type Fee Late Fee License Type Fee Late Fee Agricultural Pest Control Adviser $140.00 $70.00 Qualified Applicator Certificate $60.00 $30.00 Qualified Applicator License $120.00 $60.00 Dealer/Designated Agent License $50.00 $25.00 Apprentice Pilot Certificate $90.00 $45.00 Journeyman Pilot Certificate $90.00 $45.00
Declaration/Signature. Sign and date the renewal application.
Payment. Enclose a check or money order payable to “Cashier, Department of Pesticide Regulation” or credit card payment.
Mail. - Send payment- Completed renewal application form including the record of CE hours (courses)- Pilots medical certificate (if applicable)- Address the enclosed envelope to: Cashier, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, California95812.
Questions? Your name and license/certificate number will be posted to DPR’s web site as soon as your application is approved and logged into the database. Our Web site address is <http://www.cdpr.ca.gov/docs/license/currlic.htm>. For other questions about your application, please contact the Licensing and Certification Program at (916) 445-4038.
License/Certificate Renewal Information Providing this information is optional
(please complete the appropriate information below for license/certificate)
A. LICENSE/CERTIFICATE HOLDER INFORMATION
Name:
Address City State Zip Code C. TYPE OF EMPLOYER/BUSINESS (Please check the appropriate boxes)
Currently inactive in pest control work.
Work for governmental agency.
City County State Federal
Work for special government district.
Irrigation District School District Mosquito Abatement Other:
Work for a company that does its own pest control and does not offer its pest control services for hire to other persons.
Work for or own a Pest Control Business (check applicable ones):
Pest Control Business (for hire) - Aerial
Manufacturing/Distributing Chemical Company
Maintenance Gardener Pest Control Business Pest
Control Business (for hire) - Ground
Farm Labor Company Pesticide Dealer Business
Other:
Independent Agricultural Pest Control Adviser
D. CLASSIFICATION OF PESTICIDES
Please indicate the classification of pesticide(s) you may recommend, sell or supervise the use of, by checking the appropriate box(es) below.
General Use Pesticides Federal Restricted Use Pesticides
California Restricted Materials Not involved with application or supervising the use of pesticides
E. COUNTY REGISTRATION INFORMATION
Please indicate the county(ies) you will be working in by checking the appropriate box(es) below:
1. Alameda 10. Fresno 19. Los Angeles 28. Napa 37. San Diego 46. Sierra 55. Tuolumne
2. Alpine 11. Glenn 20. Madera 29. Nevada 38. San Francisco 47. Siskiyou 56. Ventura
3. Amador 12. Humboldt 21. Marin 30. Orange 39. San Joaquin 57. Yolo48. Solano
4. Butte 13. Imperial 22. Mariposa 31. Placer 40. San Luis Obispo 49. Sonoma 58. Yuba
5. Calaveras 14. Inyo 23. Mendocino 32. Plumas 41. San Mateo 50. Stanislaus
6. Colusa 15. Kern 24. Merced 33. Riverside 42. Santa Barbara 51. Sutter
7. Contra Costa 16. Kings 25. Modoc 34. Sacramento 43. Santa Clara 52. Tehama
8. Del Norte 17. Lake 26. Mono 35. San Benito 44. Santa Cruz 53. Trinity
9. El Dorado 18. Lassen 27. Monterey 36. San Bernardino 45. Shasta 54. Tulare
First Last
E-mail Address: Home/Cell Phone:
B. EMPLOYER/BUSINESS INFORMATION
Employer/Business Name: Business Phone:
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DEPARTMENT OF PESTICIDE REGULATION PEST MANAGEMENT AND LICENSING BRANCH
LICENSING AND CERTIFICATION PROGRAM P.O. BOX 4015
SACRAMENTO, CA 95812-4015(916) 445-4038
E-Mail: [email protected] site: http://www.cdpr.ca.gov
STATE OF CALIFORNIA
CONTINUING EDUCATION RECORD RENEWAL SUMMARY DPR-PML-123 (Rev. 7/18)
INSTRUCTIONS
CE HOURS COMPLETED
1. For each approved course completed, enter the following: title; DPR course I.D. number; location; date(s) attended; and hours completed. In the boxes located in the bottom right-hand corner, enter the total number of continuing education (CE) hours you have completed for the current renewal period. If you are using a document other than this form as proof of your CE hours, you must provide the same information. Your CE record summary must be returned with your renewal application. If the information on this form or the document you submit is incomplete, the processing of your renewal will be delayed.
2. Do not submit application and fee unless all required CE hours have been completed. If you fail to complete the required minimum CE hours by December 31 of your expiration year, you will be required to re-examine in laws and regulations, as well as all categories you held. A person who violates California's pesticide laws and regulations including making a false or fraudulent statement, record, report, or use any fraud or misrepresentation with meeting any license requirement is subject to penalties up to $5,000 per violation; this includes falsifying a CE record.
APPLICANT NAME CERTIFICATE/LICENSE TYPE CERTIFICATE/LICENSE NUMBER
CONTINUING EDUCATION COURSE INFORMATION Law
s an
d Re
gula
tions
(L)
Aer
ial A
pplic
atio
n an
dTe
chni
ques
(A)
Oth
er (O
)
Tota
l Hou
rs (T
)
COURSE TITLE DPR COURSE ID NUMBER
(L)
(L)
(A)
(A)
(O)
(O)
(T)
(T)
(L) (A) (O) (T)
(L) (A) (O) (T)
(L) (A) (O) (T)
(L) (A) (O) (T)
(L) (A) (O) (T)
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
COURSE TITLE DPR COURSE ID NUMBER
LOCATION (City and State) DATE(S) ATTENDED
TOTAL CE HOURS
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STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION 1001 I STREET SACRAMENTO, CA 95814-2828 Web site: http://www.cdpr.ca.gov DPR-105 (Rev. 08/17) Page 1 of 1
VISA/MASTERCARD TRANSACTION
Mail completed application with this payment form to:
For Licensees: For Continuing Education Sponsors:
ATTN: Cashier Cashier Department of Pesticide Regulation ATTN: CE P.O. Box 4015 Department of Pesticide Regulation Sacramento, CA 95812 P.O. Box 1379
Sacramento, CA 95812
ALL SECTIONS MUST BE COMPLETED. DO NOT E-MAIL OR FAX this form.
FAILURE TO COMPLETE ALL SECTIONS WILL RESULT IN YOUR APPLICATION BEING DELAYED OR REJECTED.
NAME OF CARDHOLDER (NAME APPEARING ON THE CARD)
VISA or MASTERCARD ONLY. No other cards are accepted.
VISA MASTERCARD CHECK ONE:
CARD NUMBER (16 DIGITS)
Expiration Date
Total Amount of Payment
SIGNATURE OF CARDHOLDER (NAME APPEARING ON THE CARD)
PAYMENT FOR:
MAILING ADDRESS (Street or P.O. Box Number)
City, State, and ZIP Code TELEPHONE NUMBER (include area code)
(DEPARTMENT USE ONLY) - ENTERED ON POS BY: TODAY'S DATE DATE MAILED BY:
